Member Reciprocal Self-Certification Form

1 California Public Employees' Retirement System Customer Account Services Division Retirement Account Services Section Box 942709. Sacramento, CA 94229-2709. TTY: (877) 249-7442. 888 CalPERS (or 888-225-7377) phone (916) 795-4166 fax Member Reciprocal Self-Certification form . Complete the following information and return this form to your Personnel Office within 10 business days: EMPLOYEE NAME: _____. (Last) (First) (Middle). SOCIAL SECURITY NUMBER OR CalPERS ID NUMBER: _____. NAME OF MOST RECENT Reciprocal RETIREMENT SYSTEM: _____. PERMANENT SEPARATION DATE FROM MOST RECENT Reciprocal RETIREMENT SYSTEM: _____. _____. FIRST MEMBERSHIP DATE IN ANY PRIOR CALIFORNIA PUBLIC RETIREMENT SYSTEM THAT IS. SUBJECT TO RECIPROCITY: _____. (Check the applicable statement). _____ I have not been a Member of another California Public Retirement System within the last six months.

2 _____ I was a Member and am retired from the _____ Retirement System and subsequently became employed by a CalPERS-covered employer. _____ I was a Member of the _____ Retirement System and became employed by a CalPERS-covered employer within six months after separating from employment with the previous Reciprocal retirement system. I understand that by accepting employment in a specific retirement system, I am subject to the applicable laws and regulations of that system. I also understand that completing this form does not constitute a request to establish reciprocity. I must complete and return the Election to Coordinate Retirement When Changing Retirement Systems, (PERS-MSD-255) form to CalPERS. I hereby certify that the foregoing information is true and correct and any information found to be incorrect may require corrections to my account in the California Public Employees' Retirement System including, but not limited to, my date of membership.

3 CalPERS may make any necessary corrections to my account to ensure I am properly enrolled and eligible to receive the correct retirement benefits. _____ _____. SIGNATURE OF EMPLOYEE DATE. TO BE COMPLETED BY EMPLOYER ONLY: NAME OF CalPERS AGENCY: CalPERS BUSINESS PARTNER ID: _____ _____. CalPERS MEMBERSHIP ELIGIBILITY DATE ORIGINAL HIRE DATE WITH YOUR AGENCY: WITH YOUR AGENCY: _____ _____. DATE Member Reciprocal Self-Certification form GIVEN TO EMPLOYEE: _____. DATE Member Reciprocal Self-Certification form RECEIVED FROM EMPLOYEE: _____. _____ _____ _____. (Please Print) DESIGNEE OF EMPLOYER TITLE DATE. _____. DESIGNEE'S SIGNATURE. PERS-CASD-801 (12/12). Member Reciprocal Self-Certification form . Instructions Reciprocity is an agreement among public retirement systems to allow members to separate from one public employer and enter into employment with another public employer within a specific time limit without losing some valuable retirement and related benefit rights.

4 The Public Employees' Pension Reform Act of 2013 (PEPRA), effective January 1, 2013, requires a CalPERS covered employer to determine the applicable PEPRA retirement benefit formula for new employees. CalPERS refers to all members that do not fit within the PEPRA definition of a new Member 1 as classic members who are subject to the Public Employees' Retirement Law (PERL). PEPRA allows a Member after January 1, 2013, to retain his/her classic Member retirement benefit status if the Member continues his/her membership in all previous California Public Retirement System(s) by leaving his/her service credit and contributions (if any) on deposit, and the Member enters into employment that results in CalPERS membership within six months of separating from the most recent California Public Retirement System. Classic Member status also requires the membership date to be on or before December 31, 2012, in a California Public Retirement System in which reciprocity is established.

5 EMPLOYER INSTRUCTIONS. 1. Employers must provide the Member Reciprocal Self-Certification form to all new employees upon eligibility for membership. 2. Employers must sign and date the Member Reciprocal Self-Certification form on the date the form is given to the employee. 3. Upon receipt of the completed Member Reciprocal Self-Certification form , the employer will enter the date the employee returns the form . 4. The employer will enroll the new employee into CalPERS membership through my|CalPERS. based on the information provided on the Member Reciprocal Self-Certification form . my|CalPERS will determine the proper retirement benefit formula. If an employer believes the retirement benefit formula is incorrect, employers may contact CalPERS at 1-888-225-7377. 5. It is the responsibility of the employer to retain the completed Member Reciprocal Self-Certification form in the employee's employment records for auditing purposes.

6 1. A new Member is defined in PEPRA as any of the following: A new hire who is brought into CalPERS membership for the first time on or after January 1, 2013, who has no prior membership in any California Public Retirement System. A new hire who is brought into CalPERS membership for the first time on or after January 1, 2013, who has a break in service of greater than six months with another California Public Retirement System that is subject to Reciprocity. A Member who first established CalPERS membership prior to January 1, 2013, who is rehired by a different CalPERS employer after a break in service of greater than six months. PERS-CASD-801 (12/12). EMPLOYEE INSTRUCTIONS. 1. The Member Reciprocal Self-Certification form will assist your employer in determining whether you are considered a new Member or a classic Member under PEPRA. 2. As the new employee, you must complete, sign and date the Member Reciprocal Self-Certification form to self-certify your most recent service in a Reciprocal California Public Retirement System, your first membership date in any previous California Public Retirement System and your permanent separation date from the most recent California Public Retirement System; or indicate that you are not a Member of any California Public Retirement System that is subject to Reciprocity.

7 3. As the new employee, you must return the Member Reciprocal Self-Certification form to your Personnel Office within 10 business days of employment. 4. The completion of the Member Reciprocal Self-Certification form does not establish reciprocity and is not a request to establish reciprocity. In order to request that reciprocity be established, visit the CalPERS web-site at: and download the publication: When You Change Retirement Systems , PUB-16. It is the responsibility of the employee to complete and send the Election to Coordinate Retirement When Changing Retirement Systems, . PERS-MSD-255 form to CalPERS. Reciprocal 1937 Act Counties Reciprocal Public Agencies Alameda Sacramento *City of Concord Contra Costa San Bernardino *City of Costa Mesa (Safety employees only). Fresno San Diego City of Fresno (Miscellaneous and Imperial San Joaquin Safety Retirement Systems).

8 Kern San Mateo City of Los Angeles (non-Safety only). Los Angeles Santa Barbara City of Oakland (non-Safety Marin Sonoma employees only). Mendocino Stanislaus City of Pasadena (Fire and Police Merced Tulare Retirement System). Orange Ventura *City of Sacramento *City of San Clemente (non-Safety employees only). Non- Reciprocal & UCRS Retirement Systems City of San Diego *City and County of San Francisco Non- Reciprocal systems are not covered by City of San Jose reciprocity retirement laws, but participate Contra Costa Water District in retirement agreements with other systems. County of San Luis Obispo East Bay Municipal Utility District State Teachers' Retirement System East Bay Regional Park District Legislators' Retirement System (Safety employees only). Judges' Retirement System Los Angeles County Metropolitan Judges' Retirement System II Transportation Authority University of California Retirement System (Non-Contract Employees' Retirement Income Plan, formerly Southern California Rapid Transit District).

9 *Also CalPERS-covered agency PERS-CASD-801 (12/12).